epiDonate - distributed serverless data infrastructure for epidemiological studies.

Motivation: Epidemiological studies face two important challenges: the need to ingest ever more complex data types, and mounting concerns about participant privacy and data governance. These two challenges are compounded by the expectation that data infrastructure will eventually need to facilitate cross-registration of participants by multiple epidemiological studies. Implementation: The portable web-service epiDonate was developed using the serverless model known as FaaS (Function-as-a-Service). The reference implementation uses nodejs. The implementation relies on a simple tokenization scheme, mediated by a public API, that a) distinguishes admin from participant roles, with b) extensible permission configuration operating a read/write structure. General Features: The critical design feature of epiDonate is the absence of business logic on the server-side (the web service). The simplicity removes the need to customize virtual machines and enables ecosystems of multiple web Applications backed by one or more data donation deployments. Availability: https://episphere.github.io/donate.

Evolution of first-line glaucoma therapy, 2007-2018: a population-based analysis.

OBJECTIVE: To evaluate the long-term evolution of first-line glaucoma therapy (FLGT) initiated by ophthalmologists and optometrists. DESIGN: Retrospective population-based study using validated provincial health care databases. PARTICIPANTS: 194,759 Ontario residents, 66 years of age or older, who received FLGT between 2007 and 2018. METHODS: A total of 194,759 individuals from 12 annual cohorts were enrolled, and rates of first-line medical treatment (prostaglandin analogue [PGA], beta-blocker, alpha-2-agonist, and carbonic anhydrase inhibitor) and laser trabeculoplasty (LT) were calculated. Provider (ophthalmologist or optometrist) rates also were assessed. RESULTS: Across the entire study period, of the 194,759 enrolled individuals who received FLGT, 60.2% initially received medical treatment and 39.8% underwent LT. Approximately 94.6% were treated by ophthalmologists. PGA therapy was the most common therapy prior to 2010, whereupon LT became the most common FLGT. By 2015, LT exceeded the total of all medications as FLGT. The annual rate of initial medication prescriptions by optometrists rose to 101.4 per 100,000 population between 2011 and 2018. In 2018, PGA and non-PGA prescription rates by ophthalmologists were 2.6 and 5.0 times higher, respectively, than prescription rates by optometrists. CONCLUSION: LT therapy has become the most common FLGT for Ontario residents 66 years of age or older. PGAs remain the most frequently prescribed glaucoma medication. While ophthalmologists continue to provide the majority of FLGT, optometrists now provide a small but growing fraction of FLGT following the introduction of glaucoma medication prescribing privileges.

Does This Patient With Acute Infectious Conjunctivitis Have a Bacterial Infection?: The Rational Clinical Examination Systematic Review.

Importance: Acute infectious conjunctivitis is characterized by ocular redness and discharge, and is a common clinical entity. Evidence-based tools to aid the clinical diagnosis of viral vs bacterial conjunctivitis are lacking and may contribute to overprescribing of topical antibiotics. Objective: To determine the relative prevalence of viral vs bacterial conjunctivitis in adults and children, and to determine which symptoms or signs are suggestive of a viral vs bacterial etiology. Data Sources: A MEDLINE search (January 1946-March 2022) yielded 1891 articles. Included articles were rated using a quality score based on a modified Rational Clinical Examination grading system. Methodological quality levels 1 through 4 required a microbiological reference standard for diagnosis, whereas quality level 5 (the lowest quality) used a clinical reference standard for diagnosis. Study Selection: Consecutive series of patients presenting with acute infectious conjunctivitis and case series of viral or bacterial conjunctivitis alone. Thirty-two studies were included in a meta-analysis to determine prevalence and diagnostic accuracy measures; 27 used a microbiological reference standard for diagnosis and 5 used a clinical reference standard for diagnosis. Results: In studies involving children (5 studies; 881 patients; mean age, 4.7 years [age range, 1 month-18 years]), the prevalence of bacterial conjunctivitis was higher than viral conjunctivitis (71% vs 16%, respectively, P = .01). In the only study of adults (n = 207 patients; mean age, 25.7 years), the prevalence of viral conjunctivitis was higher than bacterial conjunctivitis (78% vs 16%, respectively, P < .001). For the primary analysis of level 1 (n = 6) and level 2 (n = 5) studies (1725 patients total), the clinical findings that best distinguished a viral etiology for conjunctivitis from a bacterial etiology included pharyngitis (sensitivity range, 0.55-0.58; specificity range, 0.89-0.94; positive likelihood ratio [LR] range, 5.4-9.9), preauricular lymphadenopathy (sensitivity range, 0.17-0.31; specificity range, 0.93-0.94; positive LR range, 2.5-5.6), and contact with another person with red eye (sensitivity, 0.18 [95% CI, 0.14-0.22]; specificity, 0.93 [95% CI, 0.90-0.95]; positive LR, 2.5 [95% CI, 1.6-3.7]). Mucopurulent ocular discharge (sensitivity, 0.76 [95% CI, 0.60-0.87); specificity, 0.66 [95% CI, 0.58-0.73]; positive LR, 2.1 [95% CI, 1.7-2.6]) and otitis media (sensitivity, 0.24 [95% CI, 0.20-0.29]; specificity, 0.91 [95% CI, 0.85-0.94]; positive LR, 2.5 [95% CI, 1.5-4.4]) were associated with the presence of bacterial conjunctivitis. Conclusions and Relevance: In this review, bacterial conjunctivitis was more common than viral conjunctivitis in children and viral conjunctivitis was more common than bacterial conjunctivitis in adults, although the prevalence estimates were based on limited evidence. Symptoms and signs associated with a higher likelihood of viral conjunctivitis in adults and children included concomitant pharyngitis, an enlarged preauricular node, and contact with another person with red eye, and signs associated with a higher likelihood of bacterial conjunctivitis included the presence of mucopurulent discharge and otitis media, but no single symptom or sign differentiated the 2 conditions with high certainty.

Topical pain control for corneal abrasions: A systematic review and meta-analysis.

OBJECTIVES: Corneal abrasions are common ophthalmic presentations to emergency departments. Among emergency physicians and ophthalmologists, there are highly variable practice patterns with regard to management of resultant pain and discomfort. The goal of this study was to review and analyze the efficacy and safety of topical pain therapies for corneal abrasions, including topical anesthetics, nonsteroidal anti-inflammatory drugs (NSAIDs), cycloplegics, steroids, pressure patching, and the use of a bandage contact lens (BCL). METHODS: The review followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. The protocol was established a priori and published on PROSPERO (CRD42020201288). MEDLINE, EMBASE, CENTRAL, and Web of Science were searched until December 31, 2020. Primary studies comparing topical pain therapies to another therapy or control were included. Primary outcomes included percentage of corneal abrasions healed at 24, 48, and 72 hours, as well as pain control at 24 and 48 hours. Secondary outcomes included use of oral analgesia and incidence of complications. Risk of bias was assessed using validated tools. Quality of evidence was assessed using the GRADE methodology. RESULTS: Overall, 33 studies (31 randomized controlled trials [RCTs], two cohort studies) comprising 4,167 patients with corneal abrasions were analyzed. Only the data for topical NSAIDs were of adequate evidence from which to draw conclusions; topical NSAIDs demonstrated significantly reduced pain scores at 24 hours (standardized mean differences [SMD] -0.69, 95% CI = -0.98 to -0.41) and 48 hours (SMD = -0.56, 95% CI = -1.02 to -0.10) as well as 53% (95% CI = 34% to 67%) lower oral analgesia use compared to control. Based on available data, topical anesthetics, cycloplegics, patching, and the use of a BCL did not result in any significant difference in pain scores or use of oral analgesia, while no studies examined topical steroids. No interventions resulted in healing delays or significantly higher rates of complications compared to controls. CONCLUSIONS: There was strong evidence to support that topical NSAIDs reduce pain associated with corneal abrasions in the first 48 hours and the need for oral analgesia. The existing evidence was insufficient to support or refute the use of topical anesthetics, cycloplegics, steroids, or BCL for pain control in corneal abrasions. Pressure patching was ineffective at pain reduction and may increase the risk of complications. Delays in healing or other complications were not significantly different between any intervention or control for simple, uncomplicated corneal abrasions; however, larger RCTs are required to identify any differences in rare complications.

Distribution and Predictors of Initial Glaucoma Care Among Ophthalmologists and Optometrists: A Population-based Study.

PURPOSE: To evaluate evolution in the distribution of new glaucoma patients between ophthalmologists and optometrists, and to examine factors predicting provider type, in the context of expansion in the scope of optometry practice. PATIENTS AND METHODS: A population-based study was undertaken using validated datasets in Ontario, Canada from 2007 to 2018, encompassing time before and after optometry practice scope expansion in 2011. All patients aged 66 and older receiving a glaucoma suspect diagnosis or first-line therapy for glaucoma from ophthalmologists or optometrists were enrolled. Predictors of provider type were evaluated using logistic regression. RESULTS: From 2007 to 2018, 401,560 patients received initial glaucoma care, including 303,440 by ophthalmologists and 98,120 by optometrists. Population rates of glaucoma suspect diagnosis increased for both providers over the study period. The rate of therapy initiation increased annually among optometrists after 2011, while the rate remained stable over that period among ophthalmologists. By 2018, 88% of patients initiating therapy and 59% of patients first diagnosed as a glaucoma suspect received that care from ophthalmologists. In the final study year, therapy initiations per provider were lower among optometrists (median: 2/provider; interquartile range: 1 to 3) than among ophthalmologists (median: 26.5/provider, interquartile range: 10 to 53). Patients were more likely to receive care from an ophthalmologist than an optometrist if they were older, had higher ocular or systemic comorbidity, or lived in urban settings. CONCLUSIONS: Optometrists have a large and growing role in diagnosing glaucoma suspects; however, despite scope expansion, optometrists play a much smaller role in initiating glaucoma therapy.

Predictors of Initial Glaucoma Therapy with Laser Trabeculoplasty versus Medication: A Population-Based Study.

PURPOSE: To investigate patient-level factors associated with first-line glaucoma therapy with laser trabeculoplasty (LT) versus topical medication. DESIGN: Population-based study. PARTICIPANTS: All patients 66 years of age and older in Ontario, Canada, receiving first-ever therapy for glaucoma with either LT or topical medication between April 1, 2007, and March 31, 2019. METHODS: Linked health care databases were used to identify patients receiving first-line glaucoma therapy and to ascertain patient-level factors potentially associated with receipt of LT versus medication. Multivariate logistic regression analyses were undertaken. MAIN OUTCOME MEASURES: Factors associated with receiving LT versus medications were evaluated using adjusted odds ratios (ORs) for age, gender, previous cataract surgery, previous corneal transplantation, previous retina surgery, level of systemic comorbidity, socioeconomic status (SES), and rural versus urban residence. RESULTS: In total, 194 759 patients were included. Older patients were less likely to be treated with LT versus medication (≥81 years of age vs. 66-70 years of age: OR, 0.49; 95% confidence interval [CI], 0.48-0.50), whereas women were more likely than men to receive LT (OR, 1.42; 95% CI, 1.39-1.45). Previous ocular surgeries were associated with decreased probability of treatment with LT, including cataract surgery (OR, 0.31; 95% CI, 0.30-0.32), corneal transplantation (OR, 0.39; 95% CI, 0.31-0.49), and retina surgery (OR, 0.46; 95% CI, 0.41-0.51). Patients with high comorbidity were less likely to receive LT (highest vs. lowest level of comorbidity: OR, 0.94; 95% CI, 0.91-0.97). Laser trabeculoplasty use was less likely among patients at higher levels of SES (highest vs. lowest level: OR, 0.86; 95% CI, 0.84-0.89) and from a rural residence (versus urban: OR, 0.92; 95% CI, 0.90-0.95). Increasing utilization of LT over time was noted (for each additional calendar year: OR, 1.05 per year; 95% CI, 1.05-1.05 per year). CONCLUSIONS: Our results identified patient characteristics associated with use of LT as primary therapy for glaucoma, including factors related to patient demographics, ocular history, and comorbidity. Many of these associations are unexpected based on efficacy data or evidence-based guidelines. These results are topical considering growing evidence supporting use of first-line LT.

Vitritis after Boston Keratoprosthesis Type 1 Implantation.

PURPOSE: To describe the incidence, presentation, and clinical course of vitritis occurring after Boston keratoprosthesis type 1 implantation. DESIGN: Retrospective chart review. PARTICIPANTS: Medical records of all patients undergoing type 1 Boston keratoprosthesis implantation over a 4-year period were reviewed. METHODS: Cases of vitreous inflammation were classified as either postoperative (within 1 month after surgery without endophthalmitis), reactive (secondary to ocular surface inflammation), idiopathic, or infectious endophthalmitis. The presenting features and postoperative course of all patients were reviewed. MAIN OUTCOME MEASURES: Postoperative inflammation. RESULTS: A total of 110 eyes underwent type 1 Boston keratoprosthesis implantation with a median follow-up of 5.6 years. Overall, there were 21 episodes of vitritis occurring in 17 patients; 6 cases of vitritis were postoperative, whereas 5 were reactive, 7 were idiopathic, and 3 were infectious endophthalmitis. Patients with vitritis sought treatment a median of 10 months after surgery (range, 1 week-7 years). Compared with patients in whom vitritis did not develop, those with vitritis were younger (50.8 years of age vs. 62.2 years of age; P = 0.01), but with a similar prevalence of autoimmune disease (P = 1.00). Eyes with postoperative vitritis had a benign and short course, and were all managed with topical medications. Reactive vitritis occurred in association with infectious keratitis (4 cases) or corneal melting (1 case). Patients with idiopathic vitritis and endophthalmitis demonstrated similar symptoms of pain and severe vision loss. The mean duration of inflammation in patients of idiopathic vitritis was 3.3 months; all patients later demonstrated retroprosthetic membrane, and 2 patients (29%) demonstrated retinal detachment. Three of 7 patients with idiopathic vitritis underwent a vitreous tap, which showed negative results in all cases. The 3 cases of infectious endophthalmitis had a prolonged and severe course, with only 1 eye retaining functional vision. CONCLUSIONS: Patients undergoing type 1 Boston keratoprosthesis implantation are at risk of postoperative vitreous inflammation, which may present in the immediate postoperative period or years later. Cases of idiopathic inflammation may present similarly to infectious endophthalmitis, and a low threshold should be taken for performing vitreous tap and injection of antimicrobials. Caution should be exercised using sub-Tenon corticosteroids, given the high prevalence of glaucoma and possibility of exacerbating fungal infections.

Collagen cross-linking as an adjunct for repair of corneal lacerations: a cadaveric study.

OBJECTIVE: To determine the efficacy of collagen cross-linking (CXL) as an adjunct to suturing in the repair of corneal lacerations. METHODS: A cadaveric study was undertaken in which a linear 5 mm corneal laceration was created in the central cornea of 20 eyes. The eyes were then randomized to receive 1 (n = 8), 2 (n = 8), or 3 (n = 4) standard corneal sutures. The burst pressure of the wound was then measured. All eyes in the 1- and 2-suture group then underwent standard CXL, with burst pressure repeated afterward. RESULTS: The initial wound burst pressure in the 1-, 2-, and 3-suture groups was 54.9, 74.0, and 201.2 mm Hg, respectively. After CXL, wound burst pressure increased by a mean of 3.2 and 62.3 mm Hg in the 1- and 2-suture groups, respectively. This change was statistically significant in the 2-suture group (p = 0.017). After CXL, the 2-suture group still had a significantly lower burst pressure compared with the 3-suture group (p = 0.011). CONCLUSIONS: The study highlights a potential novel application for CXL to strengthen corneal wounds. Provided that suture density is sufficient to appose the wound edges, CXL may result in short-term wound strengthening. This could potentially allow for decreased corneal suture density and a corresponding decrease in suture-related complications.

Design and Validation of a Training Simulator for Laser Capsulotomy, Peripheral Iridotomy, and Retinopexy.

BACKGROUND AND OBJECTIVES: Ophthalmology trainees commonly learn laser procedures on live patients. A simulator for learning peripheral iridotomy (PI), posterior capsulotomy, and retinopexy may improve patient outcomes. MATERIALS AND METHODS: A model eye with artificial tissues was designed. The tissues reacted to laser similarly to human tissues. Inexperienced (n = 6; first- to third-year residents) and experienced (n = 7; fourth- to fifth-year residents and staff) ophthalmic personal were compared on performance of the above laser procedures. RESULTS: The inexperienced group required more shots (P = .04) and caused more lens markings (P = .04) during capsulotomy and had more incomplete retinopexy results (P = .04) than the experienced group. The groups did not differ in total shots for PI, average power for retinopexy, or the total time required for any of the procedures. CONCLUSION: Our model effectively simulates common ophthalmic laser procedures and is practical for the training of ophthalmology residents. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:56-61.].

Drug-prescribing patterns among optometrists and nonophthalmologist physicians at a tertiary care centre in Kingston, Ontario.

OBJECTIVE: To report on patterns of optometry prescribing and adherence to prescribing regulations at a tertiary care ophthalmology centre. DESIGN: Prospective cohort study. PARTICIPANTS: All new referrals from optometrists and other health care professionals to the emergency eye care service (n = 1965) between July 2011 and June 2012, as well as optometry referrals to 2 subspecialty services (glaucoma [n = 71] and cornea [n = 212]). METHODS: In our primary analysis, the frequency of prescribing and classes of medications prescribed were reported and compared amongst various referral sources to the emergency eye care service. As a secondary analysis, we reported frequency of prescribing in optometry referrals to 2 subspecialty clinics. Adherence to prescribing guidelines was reported for all optometry referrals. RESULTS: Of 296 referrals from optometrists to the emergency eye care service, 20 (6.8%) had received a prescription medication; this was significantly less compared to emergency and family physicians (p < 0.001). Topical antibiotics were the most frequently prescribed medication class. The frequency of prescribing by optometrists was 5.2% (11/212) and 4.2% (3/71) for patients referred to the cornea and glaucoma services, respectively. Among those patients referred after being given a prescription for a glaucoma medication by an optometrist, 89% cases (8/9) did not adhere to prescribing regulations. CONCLUSIONS: After the introduction of prescribing privileges, optometrists prescribe a variety of medications in their practices. Current prescribing guidelines are not always followed in practice, suggesting that continued study and collaboration is necessary to create an optimal model of interdisciplinary care that provides access to the highest quality of care.

Efficacy of Intravenous Mannitol in the Management of Orbital Compartment Syndrome: A Nonhuman Primate Model.

PURPOSE: To report the efficacy of intravenous mannitol in the treatment of orbital compartment syndrome. METHODS: An experimental study was conducted on 4 nonhuman primates (8 orbits). Orbital compartment syndrome was simulated by injecting autologous blood into both orbits of each nonhuman primate until a pressure of 80 mm Hg was reached (time 0). After 10 minutes, nonhuman primates were randomized to receive an infusion of either mannitol or saline, given over 15 minutes. Five minutes after the infusion was complete, lateral canthotomy and cantholysis was performed on both orbits in isolated steps every 5 minutes. During the study protocol, orbital and intraocular pressures were recorded every 5 minutes, with a final set of measurements at 60 minutes. The primary outcome measures were the mean change in pressure from time 0 to 60 minutes, as well as the mean change in pressure during the infusion period. RESULTS: There was no statistically significant difference in the mean changes in orbital or intraocular pressure from time 0 to 60 minutes of the protocol. However, during the infusion period there was significantly greater decrease in both orbital and intraocular pressure in the mannitol compared with saline group (-34.0 vs. -9.3 mm Hg for orbital pressure [p = 0.03]; -34.8 vs. -9.7 mm Hg for intraocular pressure [p = 0.04]). CONCLUSIONS: While the definitive treatment of orbital compartment syndrome is lateral canthotomy and cantholysis, mannitol results in a rapid and clinically meaningful drop in orbital and intraocular pressure. The authors believe that their data support the routine use of mannitol in orbital compartment syndrome, especially when there is a delay in timely surgical management.

Value of subjective visual reduction in patients with acute-onset floaters and/or flashes.

OBJECTIVE: To quantify the association between subjective visual reduction (SVR) and retinal pathology in patients with acute-onset monocular floaters or flashes, or both. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohorts study involving all new patients referred for acute-onset floaters or flashes, or both, to a tertiary care emergency eye clinic in Kingston, Ontario, between July 1, 2011, and June 29, 2012 (n = 333). METHODS: All patients were evaluated for the presence of SVR in a standardized fashion, as well as other known risk factors for retina pathology including a family history of retinal tear or retinal detachment, a personal history of retinal tear or detachment, high myopia, and ocular trauma. Our major outcome was urgent retinal pathology, defined as retina pathology requiring a same-day referral to a retina specialist for evaluation, management, or both. RESULTS: SVR was strongly associated with retinal pathology (likelihood ratio 7.9, 95% CI 5.2-12.1). CONCLUSIONS: Patients with SVR are at increased risk for urgent retinal pathology and should be triaged for urgent ophthalmologic examination.

Identifying predictive morphologic features of malignancy in eyelid lesions.

OBJECTIVE: To determine features of eyelid lesions most predictive of malignancy, and to design a key to assist general practitioners in the triaging of such lesions. DESIGN: Prospective observational study. SETTING: Department of Ophthalmology at Queen's University in Kingston, Ont. PARTICIPANTS: A total of 199 consecutive periocular lesions requiring biopsy or excision were included. MAIN OUTCOME MEASURES: First, potential features suggestive of malignancy for eyelid lesions were identified based on a survey sent to Canadian oculoplastic surgeons. The sensitivity, specificity, and odds ratios (ORs) of these features were then determined using 199 consecutive photographed eyelid lesions of patients who presented to the Department of Ophthalmology and underwent biopsy or excision. A triage key was then created based on the features with the highest ORs, and it was pilot-tested by a group of medical students. RESULTS: Of the 199 lesions included, 161 (80.9%) were benign and 38 (19.1%) were malignant. The 3 features with the highest ORs in predicting malignancy were infiltration (OR = 18.2, P < .01), ulceration (OR = 14.7, P < .01), and loss of eyelashes (OR = 6.0, P < .01). The acronym LUI (loss of eyelashes, ulceration, infiltration) was created to assist in memory recall. After watching a video describing the LUI triage key, the mean total score of a group of medical students for correctly identifying malignant lesions increased from 46% to 70% (P < .001). CONCLUSION: Differentiating benign from malignant eyelid lesions can be difficult even for experienced physicians. The LUI triage key provides physicians with an evidence-based, easy-to-remember system for assisting in the triaging of these lesions.